Lifeline Home Health Care, Inc.

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, the agency failed to notify the physician of changes in health conditions for three (Patients #1, 8 and #12) of 13 patients. Findings: Patient #1 A plan of care dated 04/03/24 to 06/01/24 documented diagnoses of chronic obstructive pulmonary disease. Documentation showed orders for SN to perform assessment and monitoring of patient’s weight every visit and report a weight loss of 3 pounds in a day or 5 pounds in a week to the physician. SN visit notes dated 04/09/24 and 04/16/24 documented the patient refused to be weighed. Documentation showed the patient had a weight of 181.2 pounds on 04/24/24 and a weight of 164 pounds on 05/29/24 (17-pound weight loss in 35 days). Documentation showed no physician provider notifications or coordination of care communications related to patient’s refusal to weigh or changes in the patient’s change in condition (17-pound weight loss in 35 days) and showed no changes in orders. On 06/18/24 at 1:32 p.m., Staff B stated the agency did not notify the physician of patient’s refusal to be weighed or changes in the patient’s condition (17-pound weight loss in 35 days). Patient #8 A plan of care dated 06/03/24 to 08/01/24 documented diagnoses of chronic kidney disease with hypertension. Documentation showed orders for SN to perform assessment and monitoring of patient’s blood sugar every visit and report a random blood sugar level greater than 200 to the physician. SN visit note dated 05/14/24 documented a random blood sugar of 239, visit note dated 05/17/24 documented a random blood sugar of 245, visit note dated 05/21/24 documented a random blood sugar of 278, and visit note dated 06/02/24 documented a random blood sugar of 209. Documentation showed no physician provider notifications or coordination of care communications related to patient’s continued elevated random blood sugar levels and showed no changes in orders. On 06/18/24 at 1:50 p.m., Staff B stated the agency did not notify the physician of the patient’s continued elevated random blood sugar levels. Patient #12 A plan of care dated 11/12/23 to 01/10/24 documented diagnoses of stage II pressure ulcer. Documentation showed orders for SN to perform assessment and monitoring of patient’s weight every visit and report weight less than 174 pounds to the physician. Documentation showed the patient had a weight of 160 pounds on 11/14/23 and a weight of 148 pounds on 12/22/23 (12-pound weight loss in 37 days). Documentation showed no physician provider notifications or coordination of care communications related to changes in the patient’s change in condition (12-pound weight loss in 37 days) and showed no changes in orders. On 06/18/24 at 1:32 p.m., Staff B stated the agency did not notify the physician of changes in the patient’s condition (12-pound weight loss in 37 days).”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure: SN to conduct weight assessment and monitoring with physician reporting parameters for four (Patients #5, 8, 9 and 12) of 13 patients and; SN to conduct pain assessment and monitoring with physician reporting parameters for one (Patient #9) of 13 patients. Findings: Patient #5 A plan of care dated 04/23/24 to 06/21/24 documented diagnoses of chronic kidney disease with hypertension. Documentation showed orders for SN to perform assessment and monitoring of patient’s weight every visit and report a weight loss or gain of 3 pounds in a day or 5 pounds in a week to the physician. Documentation showed the patient had a weight of 97 pounds on 05/02/24 and a weight of 100 pounds on 05/03/24 (3-pound weight gain). Documentation showed no physician provider notifications or coordination of care communications related to patient’s weight gain in one day and showed no changes in orders. On 06/18/24 at 1:32 p.m., Staff B stated the agency did not notify the physician provider of patient’s weight gain of 3-pounds in one day. Patient #8 A plan of care dated 06/03/24 to 08/01/24 documented diagnoses of chronic kidney disease with hypertension. Documentation showed orders for SN and CHHA to perform assessment and monitoring of patient’s weight every visit and report a weight loss or gain of 3 pounds in a day or 5 pounds in a week to the physician. SN and CHHA visit notes dated 06/03/24, 06/04/24, 06/05/24, 06/07/24, 06/10/24, 06/11/24, 06/12/24 and 06/17/24 showed no patient weight assessment and were documented as NA (non-applicable). Documentation showed no physician provider notifications or coordination of care communications related to staff unable to weigh the patient, patient refusal of weight assessment and showed no changes in orders. On 06/18/24 at 1:50 p.m., Staff B stated the agency staff did not weigh the patient as ordered in the POC. Patient #9 A plan of care dated 05/01/24 to 06/29/24 documented diagnoses of vaginal bleeding. Documentation showed orders for SN and CHHA to perform assessment and monitoring of patient’s weight every visit and report a weight loss or gain of 3 pounds in a day or 5 pounds in a week to the physician and assess patient pain level and report to the physician provider of pain levels greater than five. SN and CHHA visit notes dated 05/09/24, 05/13/24, 05/14/24, 05/16/24, 05/20/24, 05/21/24, 05/23/24, 05/27/24, 05/28/24 and 06/03/24 showed no patient weight assessment and were documented as Ua (unable to weigh) or NA (non-applicable). Documentation showed no physician provider notifications or coordination of care communications related to staff unable to weigh the patient, patient refusal of weight assessment and showed no changes in orders; and SN visit notes dated 05/14/24, 05/28/24 and on 06/04/24 patient reported a pain level of seven. Documentation showed no physician provider notifications or coordination of care communications related to patient reported pain levels of seven and showed no changes in orders. On 06/18/24 at 1:55 p.m., Staff B stated: 1. The agency staff did not weigh the patient as ordered and; 2. The agency did not notify the physician provider of patient reported pain level of seven and showed no changes in the POC. Patient #12 A plan of care dated 11/01/24 to 12/30/24 documented diagnoses of right patellar fracture. Documentation showed orders for SN to perform assessment and monitoring of patient’s weight every visit and report a weight less than 174 pounds to the physician. SN visit notes dated 11/24/23, 12/01/23, 12/06/23, 12/15/23 and on 12/27/23 showed no patient weight assessment. Documentation showed no physician provider notifications or coordination of care communications related to patient weight assessment and showed no changes in orders. On 06/18/24 at 2:00 p.m., Staff B stated the agency staff did not weigh the patient as ordered in the POC.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure documentation of SN and MSW visit notes for one (Patient #13) of 13 patients. Findings: Patient #13 A review of the clinical record showed no documentation of a MSW visit conducted on 11/13/23 and a SN visit note for visit conducted on 12/21/23. Documentation showed an entry by the social worker in a coordination note (message) on 11/13/23 that the visit was conducted but showed no documentation of the visit note and SN visit conducted on 12/21/23 was blank and not marked as completed. On 06/18/24 at 2:00 p.m., Staff B stated no MSW visit note was documented for patient #3 for MSW visit conducted on 11/13/23 and the SN visit note for 12/21/23 was blank.”